Provider Demographics
NPI:1487191102
Name:KANE, JUDIE (PPCNP)
Entity Type:Individual
Prefix:
First Name:JUDIE
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:PPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 763
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 LODGEVILLE RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1488
Practice Address - Country:US
Practice Address - Phone:304-842-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV84038363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics